Provider Demographics
NPI:1609381961
Name:HUBBARD, GEROD UNDRON JR (LAC, ATC)
Entity Type:Individual
Prefix:
First Name:GEROD
Middle Name:UNDRON
Last Name:HUBBARD
Suffix:JR
Gender:M
Credentials:LAC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4791 COUNTY ROAD 2105
Mailing Address - Street 2:
Mailing Address - City:HOOKS
Mailing Address - State:TX
Mailing Address - Zip Code:75561-7562
Mailing Address - Country:US
Mailing Address - Phone:903-278-5594
Mailing Address - Fax:
Practice Address - Street 1:425 W UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3347
Practice Address - Country:US
Practice Address - Phone:580-745-3214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9652255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer